Check/ Food Voucher Request Form - Branches

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EMERGENCY SERVICES NETWORK CHECK/VOUCHER REQUEST FORM
Requestor: ______________________________
Date of Request:______________________
Church/Site:_______________________________________________________________________________
Request: I am requesting the following:
Check
Payable to:________________________________________________________
Amount: $____________
Send Check to the following location and address:
Food Vouchers
Amount Requested: $ ____________________
Voucher Preference:
Publix: $ ______________
Winn Dixie: $ _______________
***Note a separate form must be submitted for each type of request***
With submission of this form I understand and agree to the following:
1. Any check requested above will not be released until itemized receipts detailing how the previously issued check
was spent are submitted to Branches.
2. Any food vouchers requested above will not be released until any previous food voucher signature pages are
submitted detailing who received the food vouchers.
3. Monthly reports are to be submitted every month (including months for which no funds are received) and are
th
th
due by the 15
day of the next month (e.g. July’s report is due August 15
).
Requestor’s Signature
Date
th
SEND THIS REQUEST TO: Branches 11500 NW 12
Ave, Miami, FL 33168 OR FAX: 305-688-3556
For Office Use Only:
1.
Approval Signature: _______________________
Date: ________________________
2.
Date Document(s) Received:_________________
Check #:______________________
3.
Date Check/Voucher Sent:___________________
Mail
Pick-Up
Delivery

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